The results of conservative medical management for intractable pneumothorax were analyzed in 45 patients hospitalized in our department from 2002 to 2006. The therapeutic strategy was determined by taking into consideration the degree of deaeration and re-inflation of the lung after a tube thoracostomy procedure comprising a tube thoracostomy, pleurodesis, or combined bronchial occlusion therapy. For bronchial occlusion therapy, silicon filling materials were used. For pleurodesis, adhesion was attempted under 50 cmH₂0 negative pressure. In all cases, except for 1 in the pleurodesis group and 3 cases of hospital death not related to treatment, the subjects were discharged from the hospital with deaeration stopped by the therapy selected in the initial treatment. We consider that our therapeutic strategy for intractable pneumothorax is effective, as well as very safe and reliable, as there were few cases of relapse.

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Objective: Chylothorax is a rare but serious complication following surgery for lung cancer. We reviewed our experience pertaining to postoperative chylothorax in order to evaluate our treatment strategy. Patients: From 1998 to 2008, 782 patients underwent pulmonary resection and lymph node dissection for lung cancer in our hospital. Postoperative chylothorax developed in 17 patients (2.2 %). Results: Of the 17 patients, 6 (35 %) were treated with a low-fat diet (group A), 8 (47 %) were treated with the complete cessation of oral intake (group B), and 3 (18 %) underwent reoperation (group C). The period of fat limitation was relatively longer in group C. The drainage period and the time to discharge were relatively shorter in group A. The amount of daily postoperative drainage was significantly greater in group C. Conclusion: Although most cases of postoperative chylothorax can be treated conservatively, patients with postoperative drainage of >1, 000 ml/day should promptly undergo reoperation.

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Abnormal shadows were detected in the right upper and middle lung fields of a 75-year-old male patient. Further examinations revealed a shadow in the right upper lung field, measuring 7 cm in diameter, which was found to be a fibromatosis arising from the apex of the right thoracic wall. Resection of the 1st and 2nd ribs, the associated intercostal muscles, and a portion of the pectoralis minor muscle was performed. The thoracic wall was then reconstructed using an artificial material. Histopathological examination showed a non-dense proliferation of elongated, spindle-shaped cells of uniform appearance, set in a collagenous stroma. These findings were consistent with the histopathological characteristics of a desmoid tumor, and the tumor was completely resected. On the other hand, the lesion of the middle lung field in the lower lobe, measuring 1.6 cm in diameter, was partially resected. This lesion was diagnosed to be a well-differentiated adenocarcinoma of the lung. A primary desmoid tumor arising in the chest wall is extremely rare; furthermore, there are no previous reports describing the simultaneous presence of a desmoid tumor of the chest wall and adenocarcinoma of the lung. Since desmoid tumors show locally aggressive behavior, close follow-up of any potential local recurrence is recommended.

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We report the surgical case of a 73-year-old male who presented with an ossifying stage III B carcinoid and an abnormally elevated level of serum ProGRP (627.7 pg/ml). CT revealed lymphadenopathy of the right supraclavicular fossa and superior mediastinum, and a small ossified nodule in the right upper lobe. Although we suspected small cell carcinoma due to the elevated ProGRP levels, we diagnosed this as a carcinoid based on the pathological findings of the excised supraclavicular lymph node. After excision of the supraclavicular lymph node, the levels of ProGRP decreased. Because of the decrease in ProGRP after excision of the lymph node, the insufficiency of a therapeutic effect using chemotherapy or radiotherapy, and the rarity of distant metastases in cases of carcinoid, we performed a right upper lobectomy and mediastinal lymph node dissection through a median-sternotomy. The final diagnosis in this case was a stage III B (pT1N3M0) typical carcinoid. Following surgery, serum ProGRP levels decreased to within the normal range, and a follow-up CT 14 months after surgery showed no evidence of recurrence.

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The patient was a 16-year-old female with an abnormal shadow on a chest X-ray found during a routine medical check-up. Computed tomography and magnetic resonance imaging showed a right posterior mediastinal tumor. No symptoms or abnormal laboratory values were found in the preoperative examination. At the beginning of surgery, her systolic blood pressure increased to over 200 mmHg and antihypertensive agents were not effective. The tumor was found to be hypervascularized and bled easily. Surgical resection of the tumor stabilized her blood pressure. The pathological diagnosis of the tumor was paraganglioma. Posterior mediastinal paragangliomas are rare, with only 26 cases being reported in Japan. This case suggests the necessity of a preoperative differential diagnosis of paraganglioma, as it can lead to extremely high blood pressure and massive bleeding during surgery.

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A 57-year-old female consulted our hospital because of an abnormal shadow pointed out on a chest X-ray film during a medical check-up. CT showed a mass located in the mediastinum in contact with the thyroid grand, trachea, esophagus, and aorta. MRI showed a mass consisting of cystic components exhibiting a low signal intensity on T1-weighted and high signal intensity on T2- weighted imaging. Under the diagnosis of benign mediastinal cyst, surgery was performed via a median sternotomy approach. Histological examination showed that the cyst was lined throughout by a monolayer of cuboidal epithelium with islands of parathyroid tissue in the wall. Mediastinal parathyroid cysts are very rare.

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We describe a case of squamous cell lung cancer with nephrotic syndrome in a 74-year-old man who was pointed out to have a lung tumor shadow on screening chest X-ray and malignancy on sputumcytology. He had complained of general fatigue and edema on his face and lower extremities 6 months before screening. He was diagnosed with squamous cell carcinoma of the left lower lobe and nephrotic syndrome with massive proteinuria (17 g per day) and hypoalbuminemia (1.2 g/dL). Since malignancy-associated nephropathy is well-recognized, and rest with diuretic administration alleviated proteinuria (9 g per day) and hypoalbuminemia (1.6 g/dL), we performed left lower lobectomy with renal biopsy, which revealed membranous nephropathy with the deposition of immunoglobulin (predominantly IgG) and a C3 component. The patient suffered from severe hypoalbuminemia (0.8 g/dL) soon after the surgery due to both massive postoperative bleeding and the transient deterioration of nephrotic syndrome, although the daily administration of the albumin fraction (20 g per day for 6 days) maintained the serum albumin concentration at 2.0-2.2 g/dL. At 10 days after surgery, he retained a serum albumin concentration of 2.1 g/dL without albumin administration. We suggest that surgical resection of neoplasms can be a first choice in the treatment of nephrotic syndrome if the lung cancer is resectable.

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We report a rare case of multiple nodular lymphoid hyperplasia (NLH). A 65-year-old female who had hypertension was admitted to our hospital because of abnormal shadows on chest X-ray. Chest computed tomography (CT) scan revealed multiple nodules in both lung fields. The physical findings and laboratory data were almost all within normal limits, and we considered the patient to be negative for tuberculosis, mycosis, and sarcoidosis. We suspected primary lung cancer or metastatic lung tumors. PET-CT showed no FDG accumulation. Biopsy by video-assisted thoracoscopic surgery (VATS) yielded a diagnosis of multiple nodular lymphoid hyperplasia (NLH). Multiple NLH is rare and non-elucidated entity, and difficult to differentiate it from MALT lymphoma. Further investigation with accumulated cases will be required.

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We encountered a patient who developed renal infarction after lung cancer surgery. The patient had fever, abdominal pain, and elevated levels of LDH, GOT, and GPT. Abdominal CT established the diagnosis of renal infarction. Preoperative coagulation studies revealed no abnormalities, and the patient had no history of diseases that could cause thrombosis or embolism. Examinations after the onset of the condition disclosed no abnormalities of the heart or great vessels. This patient as well as a previously encountered patient with both renal and splenic infarctions underwent left thoracotomy for lobectomy and lymph node dissection, strongly suggesting that the development of infarction was associated with surgical procedures. It is necessary to institute anticoagulative treatment promptly if organ infarction occurs.

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60-year-old woman underwent partial resection of the right lower lobe for mucoepidermoid tumor 18 years ago. She had been suffering from hemosputum for the last three months, and was referred to our hospital for medical examination. A CT scan showed an irregularly shaped tumor at the orfice of the right B10 and atelectasis of S10. Bronchoscopy showed a polypoid lesion at the B10 orfice. No evidence of malignancy was noted in spite of two independent transbronchial lung biopsies. Since the possibility of local recurrent mucoepidermoid tumor could not be excluded, right lower lobectomy was performed. Histopathologic examination revealed that the tumor was a silk suture granuloma, with no evidence of malignancy.

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We report here in two patients who successfully underwent limited surgery for the treatment of bilateral pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. The patients were a woman in her 40s and a man in his 70s, with both having no symptoms. We could not diagnose them definitely before surgery, and confirmed MALT lymphoma via intraoperative lung biopsy. Lymphomas were completely resected with a combination of partial resection and segmentectomy of the lung in the two cases. These patients received no postoperative adjuvant therapy and, at present, are alive without recurrence. Although surgical, chemotherapeutic, or radiation therapy has been reported for the treatment of pulmonary MALT lymphoma, there are no established regimens and the operative method like as the standard operation for lung cancer. To date, few reports concerning the long-term prognosis of patients with pulmonary MALT lymphoma have been published in Japan. It is important to perform long-term follow-up studies of such patients to confirm what kind of treatment for pulmonary MALT lymphoma is suitable.

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Abstract-Background, A rare pleomorphic adenoma of the lung is presented. Case, An abnormal shadow was pointed out in the left lung in 2000. Chest CT showed a pulmonary nodule in the left, lingular lobe, measuring 2.0 cm in diameter. He underwent fiberoptic bronchoscopy, but it remained indeterminate. During follow-up, the size of the tumor increased based on the findings of chest X-ray in August 2007. Thus, we decided to perform surgical intervention for the tumor, and obtained a diagnosis of pleomorphic adenoma. Conclusion, We experienced a case of pleomorphic adenoma which was followed up for more than 10 years. Pleomorphic adenoma is considered to be a benign lung neoplasm based on the histopathology, but malignant or aggressive behavior, such as local recurrence, has been reported.

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We present a case of hemothorax associated with endometriosis. A 45-year-old woman consulted the hospital for right lower abdominal pain. The symptom occurred within 5 days after the onset of menses. An abdominal CT scan revealed massive ascites and an enhanced mass on the right side of the uterus. Deterioration of anemia was noted, and bleeding from the right ovary was suspected. Laparotomy was performed. Pelvic endometriosis and about 1, 500 ml bloody ascites were found. Bilateral salpingo-oophorectomy was carried out. We identified right-sided pleural effusion on a postoperative roentgenogram. A drainage tube was inserted into the right thoracic cavity, and about 1, 300 ml of bloody pleural effusion was drained. Thoracoscopy was carried out the next day. Multiple brown spots were found on the parietal and visceral pleura and on the diaphragm. Purple spots and small pores were also found at the site of the central tendon of the diaphragm. Partial resection of the diaphragm and lung were performed. Ectopic endometriosis of the diaphragm was diagnosed pathologically.

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We report a case of intestinal metastasis from large cell carcinoma with a rhabdoid phenotype of the lung (LCCRP). A 49-year-old man suffered from bloody sputum and backache. Chest CT showed a tumor (6 cm) in the left lower lobe of the lung and bilateral bulky hilar and mediastinal lymphadenopathy, and abdominal CT showed stenosis of the jejunum due to a metastatic tumor (3 cm). Surgical resection of the jejunal tumor was performed to prevent intestinal obstruction. Histological examination revealed jejunal metastasis of LCCRP. After chemotherapy with gefitinib, the patient died of LCCRP progression on the 37th day post operation. LCCRP is classified into variants of large cell carcinoma according to the 1999 WHO classification. This histological type has more than 10% rhabdoid cells, and is aggressive and leads to a poor prognosis compared with other subtypes of large cell carcinoma. Intestinal metastasis from lung cancer may occur mainly in the poorly differentiated type of lung cancer including large cell carcinoma, and is poor prognosis even though they underwent surgical treatment.

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An 80-year-old male was found to have an anterior mediastinal tumor and a lung tumor of the left lower lobe. After a 5- month follow-up, a CT scan showed a growing anterior mediasitinal tumor and a solitary nodule in the left lower lobe. Extended thymectomy with partial resection of the right upper lobe and partial pericardiectomy were performed via a median sternotomy. During this procedure, a left lower lobectomy was performed by left 5^th intercostal thoracotomy. Pathological examination revealed the coexistence of squamous cell carcinoma of the thymus and an atypical carcinoid of the lung. Synchronous thymic carcinoma and lung carcinoid are rare.

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A 36-year-old man visited the emergency room of our hospital with sudden epigastralgia after dinner. Abdominal echo and CT revealed no abnormality. He subsequently developed a fever of about 38°C. Two days later, he visited the Department of Respiratory Division with worsening symptoms. At that time, he still had a fever of about 38°C. Laboratory data showed inflammatory changes, and an enhanced chest CT revealed bilateral pleural effusion and a ring-enhanced cystic shadow in the subcarinal area. This led to a suspicion of mediastinal abscess, and he was operated on emergently on the day of admission. The lesion was hard and white, and friable tissue suggesting necrosis was observed. The lesion was only biopsied because it invaded neighboring structures and was unresectable. Pathological examination revealed a large necrotic area and the diffuse proliferation of large lymphoid cells with atypical nuclei, leading to a diagnosis of diffuse large B-cell lymphoma pathologically and immunohistologically. Malignant lymphoma with a cystic shadow is very rare.

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An 89-year-old man experienced right back pain and swelling 2 months previously. He underwent artificial pneumothorax (AP) for tuberculosis 60 years ago, and the empyema cavity caused by AP was curetted when he was 79 years old. Chest X-ray showed a mass and destruction of the eighth rib. Chest CT showed the presence of a slightly enhanced 8×5.5×3.5 cm mass with destruction of the eighth rib. FDG-PET imaging identified the positive accumulation of the tracer only in the mass. We performed a biopsy, and suspected malignant fibrous histiocytoma. We thought that radiation therapy was the optimal treatment for our patient because of his age. However, since the bleeding from the biopsy site continued, we had to excise it with a part of the chest wall that included the seventh, eighth, and ninth ribs. The tumor did not invade the lung. The histopathologic diagnosis was epithelioid angiosarcoma occurring in the chest wall after curettage. There was no recurrence at 1 year after the surgery. Angiosarcoma is a well-known disease that occurs after chronic empyema, similar to pyothorax associated lymphoma. This was a rare case because the patient was a very old man when his chest wall tumor was excised, and this tumor developed long after curettage of chronic empyema.

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A 77-year-old man was admitted to our hospital for chronic empyema with pulmonary fistula following artificial pneumothorax for the treatment of pulmonary tuberculosis at the age of 20. Because chest tube drainage failed to control the inflammation and close the fistula, fenestration was performed. At approximately 2 years after surgery, a small tumor appeared, arising from the opened chest wall. Biopsy revealed the tumor to be malignant lymphoma. Local resection with a wide margin was carried out under local anesthesia. The patient has remained free from local recurrence and distant metastasis during the 13 months since the operation. We should be aware that pyothorax-associated lymphoma might occur even after fenestration for the therapy of chronic empyema.

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We present three cases of pulmonary cryptococcosis. An abnormal chest shadow was detected on annual screening in all cases. FDG-PET was performed in all cases, and showed the accumulation of FDG. The standard uptake value (SUV) ranged from 0.98 to 4.70. Wedge resection or segmentectomy was performed in all cases to facilitate a pathological diagnosis revealing Cryptococcus fungal bodies. After surgical resection, no sign of relapse has been seen in any of the patients. There are some cases negative for serum antigen in immunocompetent patients. It has been reported that chest CT findings and the accumulation of FDG do not make it easier distinguish pulmonary cryptococcosis from malignancy. Surgical resection is recommended for both the diagnosis and treatment of pulmonary cryptococcosis.

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We report the case of a 15-year-old woman who was referred to a previous hospital with a chest CT showing an abnormal mass in the upper mediastinum. The tumor showed a low-level uptake of FDG-PET. We performed resection of the mediastinal tumor, which was diagnosed as a Castleman's disease. Upper mediastinal Castleman's disease in childhood is a very rare disease, and several cases have been reported in Japan.

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